Question on chest tubes!

For a client who is post right upper lobe lung resection via a video assisted thoracoscopy (VATS), why does he/she require 2 chest tubes inserted in the right chest?

I understand that the tubes are for removal of fluid and air in the pleural spaces and what not, but I don't understand the specific reasons behind TWO chest tubes, or three in other cases. I'm guessing, each lobe has their own tube?...

Also, if for example, the client accidentally tips over their CDU, spilling the drainage into all the chambers, how do we change the CDU without loosing any drainage so that we can measure it?

Thank you all in advance!!!

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When the atrium tips over, you can do one of two things. You can either mark the drainage where it ended up and keep measuring, or you can change the atrium entirely. As long as your marking your drainage and recording it you should be all set either way. Hope this helps

I would say that changing the system increases your patient's risk of infection without gaining any advantage whatsoever in obtaining information on output.

As a thought experiment, imagine that before the thing got knocked over it held exactly 400cc. Now there's 150cc in one place, 250cc in another. Tomorrow you hear that somebody kicked it over again (!) but now there is 300cc in the first chamber and 150cc in the second. How much new drainage is that?

OK, OK, they really want to know if you can describe the steps and rationale for changing the collection device. Just so you know, the amount in there has nothing to do with that. Let's talk about chest tubes in general.

This little tutorial started out with a few sample NCLEX questions someone posted. I answered this one....

<< On the way to an x-ray examination a client with a chest tube becomes confused and pulls the chest tube out. The nurse's immediate action should be to:

1. Place the client in Trendelenburg position.
2. Hold the insertion site open with a Kelly clamp.
3. Obtain sterile Vaseline gauze to cover the opening.
4. Cover the opening with the cleanest material available.>>

As always in NCLEX-land (and in real life), you're looking for the answer that keeps the patient safest. I know you'd rather cover that hole with something sterile, but what is a greater immediate danger to this unfortunate fellow, an infection (which may not even develop) or a great honking pneumothorax (which certainly will)?

And while we're at it, let's talk about how you know whether to clamp or not to clamp a chest tube that has been disconnected from its drainage device (but is still in the pleural space) (this will answer your exam question about changing drainage devices). To understand this, let's look at the differences between a tension pneumo and a pneumo that isn't a tension pneumo .

Respiratory mechanics first ! When you breathe in, you're not actually pulling air into your lungs with your muscles. You're actually making a suction inside your chest with them (I know this may seem like a distinction without a difference, but stay with me), and the air enters the lungs thru the route provided for it to do so-- your trachea, via your nose or mouth (or trach tube, if you aren’t so lucky).

Your lungs are covered with a slippery membrane called the visceral pleura. The inside of your chest wall has one too, the parietal pleura. They allow the lungs to slip around with chest wall motion, like you can slip two wet glass plates around that are stuck together. Like the two glass plates, they're hard to pry apart due to the surface tension of the wet between them, and that's why the lungs fill the chest cavity and stay there. But just as you can easily pop those glass plates apart if you get a teeny bit of air between them, you can pop the bond between the two pleural layers with air, and if you do, the natural elasticity of the lung will cause it to collapse down to about the size of a goodish grapefruit.

How does the air get in the pleural space where it doesn’t belong? Well, you can do it two ways. One is to play rough with the bad boys (or have surgery, which is, after all, only expensive trauma) and have a sharp object puncture your chest wall and admit air into the pleural space. How does it get in there? Well, you make suction in your chest when you breathe in, and now air has TWO routes to get inside your chest-- down the trachea into the lungs, and thru the hole in the chest wall into the pleural space. This is called a pneumothorax, air in the chest that is outside of the lung. The lung will tend to collapse because the surface tension between the wet layers is now interrupted (remember how the pieces of wet glass can be separated by introducing air between them?) and the lungs are naturally elastic.

The other way to get air into your pleural space is from having blebs/bullae on your lung surfaces, and pop one (or more), or have some other hole in your lung (sharp things again). Then air gets out of your lungs thru the hole(s) and disrupts that pleural side-to-side thing, and there you go again, a pneumothorax. This, however, is called a TENSION pneumothorax, because that air increases with every exhalation (the lung now having two routes to exhale air out of, the trachea and the hole in the lung itself). This allows the lung to collapse on that side, and soon enough pressure (tension) will develop in that half of the chest to push the chest contents over to the other side, compromising blood flow and air exchange in the other lung & heart when it does so. (This is when you see the "tracheal shift.") This is also a bad thing.

So: now both of these fine folks have bought themselves chest tubes. The guy with the chest wall trauma has had his trauma hole sewed up, so when he takes a deep breath air enters his trachea only. He has a water seal on his chest tube so he can't pull air into his chest thru the tube-- the water seal acts like the bend in your sink drain and prevents continuity of the inside and outside places. The suction on the chest tube setup has done its job of removing the air from the pleural space where it didn't belong--it was seen bubbling out thru the water seal and then couldn't get back in. (When all the air is gone from his pleural space, there will be no more airleak in the water seal compartment.) Now, if he disconnects his Pleurevac (or other copyrighted device), he can again take a deep breath and pull air thru the open tube into his pleural space, where it doesn't belong, collapse his lung, and start all over again. THEREFORE, when this guy disconnects his tube, you clamp it IMMEDIATELY, to prevent air from entering the pleural space. He should ALWAYS have those two big old chest tube clamps taped to his Pleurevac (so they go with him to xray and all), just in case he does this.

However, the other guy, with the ruptured blebs or a raw surgical surface from a wedge resection and the intact chest wall? Well, his chest tube is pulling air out of the pleural space, but more is still getting in there since he still has a hole in his lung. The idea of the CT is to pull it out faster than he can put it in, and allow the hole to heal up, at which point he will no longer collect air in his pleural space and be all better. Meanwhile, though, you see air bubbling in the waterseal chamber, showing you that there is still air being pulled out of his pleural space. He has “an air leak.” What happens to him if his chest tube gets disconnected?

Well, remember, he still puts air into his pleural space, because there's still a hole in his lung. You put a tube in there to take it out, remember? OK, so what happens if you clamp his tube? Bingo, air reaccumulates in the pleural space all over again, his lung collapses, and things go to hell in a handbasket. This guy should NEVER have clamps at his bedside, because some fool may be tempted to clamp his tube before his airleak seals, and he'll get in trouble all over again. If he pulls his tubing setup apart, have him breathe slowly and shallowly (to minimize the air leaving the hole in his lung and getting trapped in his pleural space) while you quick-like-a-bunny hook him up again to a shiny new sterile setup. But do NOT clamp his tube while your assistant gets it set up for you.

Every tube needs to be connected to some sort of drainage device (or at least a Heimlich valve to prevent air entry on inspiration), but I've seen a lot of paired tubes with a Y-connector connecting them both to just one. I'm not sure I understand what you mean, unless it's that a chest tube drainage system has to have a drainage chamber and an airlock chamber (waterseal or other equivalent). Maybe there's some reason they expect different drainage from each to tell them something? (thpugh I can't think what that might be)

1) The 2 chest tubes are attached to dual chamber chest drainage unit. How does this work?
When it says "dual" does that mean that its just one drainage device, and the 2 chest tubes are connected via the Y-connector as you said? If so, then this is a mistake on my part! In my head i am imagining some sort of device that is specifically made for patients with 2 chest tubes... Could you clarify this for me?

2) The pt goes out for a walk and then their CDU tips over, spilling drainage into all the chambers. In order to accurately measure the drainage, the CDU must be changed. Describe the procedure and what you would tell the pt.
And for this question, well... I've argued that changing the CDU would only increase the risk of infection and that the drainage amount can still be properly measure even if the drainage has spilled into the other chambers. Im still waiting for my professors reply for this question.